From the Guidelines
CT scanning is the gold standard for identifying fractures of the thoracolumbar spine in trauma patients, with a reported sensitivity of 94% to 100%. The use of CT scanning is recommended due to its superior sensitivity for detecting fractures compared to radiographs, which have a reported sensitivity of 49% to 62% for identifying thoracic spine fractures and 67% to 82% sensitivity for identifying lumbar spine fractures 1.
Key Points to Consider
- CT scanning is excellent for delineating soft-tissue injuries of the chest, abdomen, and pelvic region that often accompany spinal fractures 1.
- The use of routine body imaging protocols for CT scanning has been shown to be comparable to dedicated thoracolumbar spine reformatted images, with a sensitivity of 94% to 99% compared to 97% to 99% sensitivity using dedicated thoracolumbar spine protocols 1.
- Obtaining sagittal and coronal spine images from existing chest, abdomen, and pelvis CT data is a recommended practice that is both effective and radiation dose sparing 1.
- MRI should be performed when there is neurological deficit or suspicion of ligamentous injury, disc herniation, or spinal cord involvement 1.
Clinical Approach
The imaging approach should be tailored to the clinical presentation, with unstable patients receiving focused assessment based on their most concerning symptoms. CT scanning may be used as the primary imaging modality for patients with significant trauma mechanisms, such as high-energy impacts, falls from height, or those with altered mental status. Patients with persistent pain despite negative initial imaging may benefit from additional studies. Early and appropriate imaging is crucial for timely diagnosis and management of lumbar spine injuries to prevent neurological deterioration and optimize outcomes 1.
From the Research
Lumbar Spine Imaging Standard in Trauma
- The standard for lumbar spine imaging in trauma patients involves the use of various imaging modalities, including radiographs, computed tomography (CT), and magnetic resonance imaging (MRI) 2, 3.
- CT without contrast is generally considered the initial line of imaging for cervical and thoracolumbar spine trauma patients, with radiographs required if CT is unavailable or unaffordable 3.
- MRI is indicated in cases with neurological involvement, advanced cervical degenerative changes, and to determine the extent of soft tissue injury, such as disco-ligamentous injuries and epidural space compromise 4, 3.
- MRI is also usually performed when X-rays and CT are unable to correlate with patient symptomatology 3.
Specific Considerations for Lumbar Spine Imaging
- In patients with ankylosing spinal disorders, the routine use of MRI may be limited to those with nonankylosed levels in which a disco-ligamentous injury may have occurred, and in patients with neurological deficits that require investigation of the spinal canal to assess for causes of neurological injury 5.
- CT findings, such as facet joint alignment, widening, pedicle or lamina fracture, spinous fracture, interspinous widening, vertebral translation, and posterior endplate fracture, can predict posterior ligament complex injury in patients with acute thoracic or lumbar spine fractures 6.
- The presence of a single abnormal CT finding may warrant confirmatory MRI for posterior ligament complex injury, while two or more CT findings may have adequate specificity to avoid the need for MRI prior to surgical intervention 6.